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Rural health values

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Some are arguing that rural Idaho hospitals need Medicaid Expansion to survive. I’m arguing we will need more than a simple yes vote on Proposition 2 on the November ballot. That’s just an important first step. For American healthcare to serve our citizens, big cities and small towns, we are going to need to ask and answer some hard questions.

Thirty years ago, I took a break from my 36-hour hospital shift in residency to listen to a lunch presentation from the CEO of a big Eastern Washington health insurance company; like he was a visionary. The food was free. He outlined the three biggest threats to US health care: AIDS, Alzheimers, and rural hospitals.

I really only remember his solution for the third: “What most small towns need is just an urgent care facility and a helicopter pad. They don’t need hospital beds.”

As a resident learning Family Practice and planning to give full spectrum care to seriously ill folks, deliver babies and do C-sections in a small town I thought he was crazy. But the health care market place as it is currently structured has me wondering, and Idaho is a great place to pose this question.

So, what value does your hospital bring to your community?

I ask this as a doctor who has worked in many small north Idaho towns. Is there value that your baby be delivered close to your home? Is it valuable that your grandparent be cared for close to home? Is it vital that health care jobs are available in your town? Does your small-town hospital add value to your community?
The insurance company CEO saw little value in keeping sick people that couldn’t be quickly patched up in an urgent care facility close to home. Big city hospitals could be more efficient, had more technologic treatments, and thus could bill for more expensive care. The medical business model as his vision saw it provided a simple solution: more helipads.

I also remember this quote from a big city hospital executive: “My hospital earns $50,000 when we amputate a diabetic’s diseased foot. But we lose $50 every time we counsel him to manage his diabetes.” Think about those incentives.

Proposition 2, Medicaid expansion, will simply provide that some folks who don’t have insurance now and get care at your small-town hospital have their care paid for by their insurance: Medicaid. Many currently get care and have no method to pay. The hospital provides the care, then scrambles to make ends meet.

In the last 8 years across the country there has been a spike in small-town hospital closures, though none in Idaho. The county indigent payments (after liens are filed and bankruptcy insured) and state tax funded Catastrophic Fund have barely supported small hospitals. Rural hospitals in states that expanded Medicaid eligibility were very much less likely to close.

Medicaid expansion, Proposition 2 on Novembers ballot will make rural hospitals more secure financially in our current system. But the system has to change. Community conversations about what services add value, are vital, or unnecessary will help this system change. Talk to your hospital board members. Let them know what you think. But if you value your local hospital, you should vote for Proposition 2.
 

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